Olivier Mares

Idiopathic avascular necrosis of the scaphoid: 10 new cases and a review of the literature. Indications for Preiser's disease

INTRODUCTION Avascular necrosis of the scaphoid (Preisers disease) is a rare entity for which there are no treatment guidelines to date. The aim of this study was to delineate the optimal treatment at different stages of this disease, based on an analysis of the cases treated in our department. MATERIALS AND METHODS Ten wrists (nine patients) were retrospectively reviewed after a mean 92 months of follow-up. The initial diagnosis was stage II avascular necrosis in four cases, stage III in four cases and stage IV in two cases. These patients were treated by conservative treatment (non surgical) in three cases, vascularized bone graft in two and palliative treatments (proximal row carpectomy or partial fusion) in five. Radiological examination, sometimes completed by MRI, and functional assessment of range of motion, grip strength and Mayo Wrist Score were performed. RESULTS Completely different results were obtained in the two stage II cases treated by conservative treatment, while functional results improved in the two cases treated by vascularized bone graft with regression of necrosis on MRI. Pain improved following palliative treatment in 4/5 stage III and IV wrists. Functional results were satisfactory with conservative treatment in one stage IV case for 13 years but worsened at the final follow-up assessment. DISCUSSION A review of the literature, including 126 cases in 29 articles clarified the role of conservative treatment, vascularized bone grafts and proximal row carpectomy in the treatment of avascular necrosis of the scaphoid. Conservative treatment is ineffective in the early stages and nearly always results in disease progression. In contrast vascularized bone grafts can stop or even reverse damage at stage II. Palliative treatment is indicated when facing irreversible lesions. LEVEL OF EVIDENCE Level IV - Retrospective study.

Clinical results of endoscopic treatment without repair for partial thickness gluteal tears

INTRODUCTION Various surgical treatments have been proposed for greater trochanteric pain syndrome (GTPS) related to gluteal tendinopathy with partial thickness tears. The clinical results of endoscopic debridement without repair of these gluteal tears are not well known. The objectives of this study were to determine if this procedure leads to: (1) reduction of pain, (2) functional improvement, (3) patient satisfaction (on scale of 0 to 10). HYPOTHESIS Endoscopic treatment without tendon repair provides short-term pain relief in patients with GTPS due to partial thickness gluteal tears. MATERIAL AND METHODS Seventeen patients (16 women, 1 man) with GTPS due to partial thickness gluteal tears that was present for at least 6 months and was refractory to conservative treatment were included in the analysis. The average age at the time of the procedure was 53.5years (17-71). Pain was evaluated with a visual analogue scale (VAS). Functional outcomes were defined using the Harris Hip Score and the UCLA activity score. Satisfaction was evaluated using a VAS and Odoms criteria. RESULTS The average follow-up was 37.6months (12-48). The average preoperative and follow-up values were respectively: (1) Pain: 7.2±1.1 (5-9) versus 3.3±1.9 (1-7) (P<0.001), (2) Harris score: 53.5±8.4 (36-68) versus 79.8±14.7 (45-96) (P<0.001). Seven patients (41.2%) were able to resume sports activities. The average satisfaction score for the surgery was 6.2±2.4 (0-9) at follow-up. Five patients had a poor outcome at the review: four still had pain and one had recurrence of the lateral snapping hip. CONCLUSION Endoscopic treatment without repair of partial thickness gluteal tears is a treatment option with modest clinical results for GTPS patients refractory to conservative treatment. LEVEL OF EVIDENCE IV, retrospective study.

A new single volar approach for epiphyseal ulnar and radial-sided comminutive fracture of the distal radius: the mediolateral windows approach.

Articular comminuted distal radius fractures are still a surgical challenge. The development of volar locking plate device allows a stable and anatomic restoration of the distal radius. We propose a modification of the classic anterior approach for articular fracture of the distal radius with ulnar impaction. By a single incision, we realize 2 windows to expose the medial and lateral column of the distal radius. This technique is indicated for complex articular distal radius fractures associated with an ulnar comminution. The dissection is extended superficially to the ulnar side of the carpal tunnel elements by a blunt dissection of the anterior part of the wrist between the skin and the superficial layer of the flexor carpi radialis, in subcutaneous tissues and the antebrachial fascia to preserve the sensitive branch of the median nerve. This new approach allows reduction of each fragment of a comminutive articular fracture without exposing the flexor tendon and median nerve to excessive tension. In our surgical armatorium, we reserved this technique for distal radius fractures with articular ulnar damage because of the possible risk to the median cutaneus branch.

« Mains de portière » : classification lésionnelle et stratégie thérapeutique

UNLABELLED The term Rollover hands (ROHs) corresponds to a loss of compound tissue from the back of the hand. Our aim was to specify the injuries associated with this type of accident and codify the therapeutic strategy. PATIENTS AND METHOD Twenty-one ROHs were reviewed with an average follow-up of 38 months. Skin coverage included 15 pedicle flaps (two posterior interosseous, 13 pedicled groin flaps), and three free flaps (two external brachial or one parascapular). RESULTS We identified: seven stage IA injuries where the extensor apparatus could be directly sutured; Seven stage IB injuries requiring a tendon graft; Stage II, like stage 1B but with bone and joint lesions or damage to the wrist extensors as well, and Stage III for which over 50% of the intrinsic muscles had been destroyed. All patients recovered their grasp. The mean active extension deficit for each finger was -20.9° for the whole digital chain and a 194.4° TAM. Palmo-digital grip strength was 51.3% on the controlateral side, and the mean DASH score was 16.1. DISCUSSION Our study demonstrates the prognostic value of the proposed classification and importance of restoring high-quality skin covering. Reconstruction of the extensor apparatus must be envisaged once the condition of the bone and joints has become stable. Vascularised tendon grafts may be indicated when early mobilisation allowing restoration of a glliding surface around the tendon is impossible, or for loss of substance of over 5 cm. Damage to the intrinsic muscles is a very poor prognostic factor.

Does Endoscopic Piriformis Tenotomy Provide Safe and Complete Tendon Release? A Cadaver Study

BACKGROUND Endoscopic piriformis release (EPR) is among the available treatments for piriformis syndrome. This procedure typically involves dividing the muscle near the sciatic nerve in the sub-gluteal space, which contains numerous blood vessels and nerves. The objectives of this prospective cadaver study were: 1) to assess the reproducibility and quality of endoscopic piriformis tenotomy near the greater trochanter; 2) to detect iatrogenic injuries to the lateral hip rotators, nerves, and vessels; 3) and to define the surgical safety margins relative to the sciatic nerve and inferior gluteal bundle. HYPOTHESIS EPR at the greater trochanter ensures full release of the muscle with a limited risk of neuro-vascular injury. MATERIAL AND METHODS EPR was performed via two portals on 10 cadaver hips preserved in zinc chloride and placed in the prone position. A third, ancillary portal was required in 7 cases. The area was then dissected with the Kocher-Langenbeck approach to allow an assessment of the tenotomy, detect iatrogenic injuries, and measure the distances separating the tenotomy site from the sciatic nerve and inferior gluteal artery. RESULTS Complete tenotomy was achieved in 9 (90%) cases. The tendon adhered to the capsule in 2 (20%) cases and showed acquired avulsion in 1 case. No injuries to the sciatic nerve or inferior gluteal artery occurred. Mean distances from the tenotomy site were 5.21±0.59cm (range, 4.5-6.6cm) for the sciatic nerve and 7.1±0.89cm (range, 5.4-8.5cm) for the inferior gluteal artery. DISCUSSION EPR by a tenotomy at the greater trochanter without sciatic nerve release provides full release of the muscle with satisfactory safety margins and a short learning curve. LEVEL OF EVIDENCE III, prospective cadaver case-control study.

Arthroscopic Dorsal Capsuloplasty in Scapholunate Tears EWAS 3: Preliminary Results after a Minimum Follow-up of 1 Year

Purpose We retrospectively evaluated the results of all arthroscopic dorsal scapholunate (SL) capsuloplasty without pinning in patients presenting predynamic instability and dorsal capsuloscapholunate septum lesions on arthro‐computed tomography scan after failed medical treatment. Materials and Methods Fifteen patients, mean age 34.3 years, underwent all arthroscopically assisted dorsal capsuloplasty. Patients were assessed preoperatively and postoperatively by a clinical (pain, Watsons test, range of motion, and strength), functional (quick disabilities of the arm, shoulder, and hand), patient‐rated wrist evaluation, and Mayo wrist score scores), and radiological (SL gap and dorsal intercalated segmental instability [DISI]) examination. SL tears were evaluated during surgery by European Wrist Arthroscopy Society (EWAS) classification. Results The mean follow‐up period was 20.2 months (range, 12‐41). Preoperatively, positive Watsons test was noted in all cases. DISI deformity was noted in three cases without any SL gap. The SL instability was graded EWAS IIIB (n = 8) or EWAS IIIC (n = 7). Postoperatively, positive Watsons test was noted in only one case. Activity pain decreased from 7.8 preoperatively to 2.4 postoperatively. Range of motion in flexion‐extension increased from 92.9 degrees preoperatively to 126.2 degrees postoperatively. Grip strength increased from 24.2 preoperatively to 38.2 postoperatively. At final follow‐up, range of motion in flexion‐extension and grip strength were estimated at 87 and 91% compared with contralateral side, respectively. All functional scores were significantly improved at the last follow‐up. No radiographic SL gapping in grip views or DISI deformity was noted. Discussion Cadaveric studies demonstrated that the dorsal portion of SL ligament is critical for the stability of the SL complex. The entire arthroscopic SL capsuloplasty technique provides reliable results for pain relief, avoiding postoperative stiffness associated with open procedures. It is an alternative technique for patients with predynamic SL instability after failure of medical management and shall not prelude the resort to any further open procedure. Level of Evidence This is a level IV, case series.

Bilateral simultaneous endoscopic carpal tunnel release: Mean time to resume activities of daily living and return to work

The purpose of this study was to determine the time needed to return to personal and professional activities after bilateral simultaneous endoscopic carpal tunnel release. During a retrospective, single-center study, we included a cohort of 30 patients (60 wrists). Patients were evaluated clinically (pain, paresthesia) and functionally (QuickDASH score) pre- and postoperatively. At the last follow-up, patients completed a questionnaire regarding the time needed to resume personal activities using the ADL scale (feeding, personal hygiene and dressing) and return to work. We also evaluated procedure satisfaction and willingness to undergo the surgery again. The average patient age was 60.5 years (range 39-86). At the last follow-up, average time to resume personal activities was 2.2 days (0-14) for feeding, 4.4 days (0-15) for personal hygiene and 3.9 days (0-14) for dressing. Average time to return to recreational activities was 11.7 days (1-60). Average time to return to work was 36.6 days (15-60). Overall, 97% of patients were satisfied or very satisfied with the outcome. All patients would have the bilateral simultaneous surgery again. Bilateral simultaneous endoscopic carpal tunnel release is rarely performed. For mild conditions, contralateral symptom improvement is common after unilateral surgery. Bilateral simultaneous endoscopic carpal tunnel release appears to be disabling right after surgery, but clinical and functional scores are similar after the third postoperative day. These data can be used for patient education and decision making when considering surgery bilateral carpal tunnel syndrome. Bilateral simultaneous endoscopic carpal tunnel release is a feasible and safe procedure. LEVEL OF EVIDENCE Level IV, case series.